KEYWORDS osteoporosis, bone mineral density, cognitive impairment, white matter disease, ischemic stroke 2 Abstract Background Little is known about the effect of osteoporosis at the acute and recovery phase of stroke on cognitive function. We evaluated the effect of osteoporosis on cognitive function in patients with ischemic stroke aged >50 years. Methods We retrospectively examined consecutive patients with acute stroke hospitalized between 2016 and 2018. Osteoporosis was defined as a T score of <-2.5 for the femoral neck or lumbar spine bone mineral density. The primary outcome was cognitive impairment measured by the Korean Mini-Mental State Examination in the acute phase and recovery phase of ischemic stroke. The association between osteoporosis and the severity of cognitive impairment was investigated using a multivariate analysis. Results Of the 260 included subjects (107 men and 153 women), 70 (26.9%) had osteoporosis. Cognitive impairment was more severe in the osteoporosis group than in the non-osteoporosis group (30.5% versus 47.1%, p=0.001). After recovery phase of stroke, the proportion of patients with cognitive impairment remained higher in the osteoporosis group. The multivariate analysis revealed a correlation between a low femoral neck bone mineral density and severe cognitive impairment in the acute and recovery phases of stroke (adjusted odds ratio [OR] 3.66, 95% confidence interval [CI] 1.05-12.79 in the acute phase and adjusted OR 11.17, 95% CI 1.12-110.98 in the recovery phase), whereas lumbar spine osteoporosis was not associated with cognitive impairment. Conclusions Low bone mineral density is associated with poor cognitive function in patients with acute stroke. Early bone mineral density assessments during acute stroke, particularly at the femoral neck, may be a useful marker of cognitive function.